Distrust and Health Reform

The public smells a rat

A fine piece last Wednesday by Politico’s Carrie Budoff Brown dissects what political prognosticators from Bill Clinton to Obama pollster Joel Berenson had predicted about the ultimate acceptance of health reform legislation. “Rarely have so many political strategists been so wrong about something so big,” she writes. “At the six-month mark, the law remains a riddle for political analysts, lawmakers and the White House.”

Riddle? Not really. Months ago the public sensed a bait and switch, and the media weren’t helping them out. The seeds of the public schizophrenia over reform were sown during the presidential campaign, when candidates Obama and Clinton talked about universal health care, making it seem that the country was on the verge of adopting a true national health insurance system like the rest of the developed world.

That’s not what they had in mind, and universal health care morphed into universal coverage provided by private carriers. Then the pols and the press discarded that term when the rationale for reform became insurance market reform—a snoozer for sure.

The constant bashing of insurance companies by the president, his health secretary Kathleen Sebelius, and advocacy groups did not compute with the public. Many Americans have had wicked experiences with insurers—but if they are so evil, why give them twenty-five million new customers? At the gut level, that didn’t make sense, and media explanations about bringing everyone into the risk pool didn’t resonate. But probing further would bring up the nasty, controversial subject of the individual mandate—the requirement that everyone have insurance. The pols were not eager to talk about the central feature of the legislation, and the press didn’t discuss it much either.

If they did, that might have raised another better-to-ignore topic, affordability: whether middle income folks would really be able to afford a policy they will be required to buy, even with government tax credits to help pay the premium. Last week I interviewed twenty-eight-year old Michelle Zywicki in the Waupaca, Wisconsin public library. She doesn’t earn much working twenty hours a week at Dollar General, and can’t find a full time job. She has no insurance. Zywicki heard she would have to pay a fine for not buying insurance which she cannot afford.

Because her income is low, I told her, she probably would get large subsidies when the mandate took effect. “Why hasn’t anyone told me that?” she shot back angrily. “I’ve tried to read articles and they put me to sleep.” Somehow, dear colleagues, we’ve missed with her—and probably millions more in her shoes.

The president’s equivocation on the public option allowed its large number of supporters to believe it was possible to create an alternative to private insurance, only to have their hopes dashed when it became clear the mighty stakeholders didn’t want it, and so the pols threw it under the bus. Nancy Pelosi herself kept telling reporters that the House bill would have a strong public option, perhaps knowing all along it wouldn’t make the final cut. To the public, Pelosi’s remarks came across as just another politician’s flimflam.

A month ago in Columbia, Missouri, holding one of my periodic town hall meetings, I talked to fifty-six-year-old Charles Paxton, who told me: “When they started it, I was for the law. By the time they got it done, I thought it was not a good idea. There were way too many compromises made to get it passed. You know it’s not going to do what it should.” What news there was of the president’s deal making with insurance companies, doctors, hospitals, and drug companies didn’t sit well with people who thought those days were over.

Republicans have exploited this distrust that is likely to intensify as more people learn about the mandate. “I don’t like the fact people will be forced to buy insurance,” said Hannah Spratt, a University of Missouri sophomore who is not spending her time watching Glenn Beck. Robert Hanna in Lincoln, Nebraska, told me he would never vote for a Democrat ever again, because the president “said he wouldn’t sign a bill that would increase the deficit and include illegal aliens which the bill does.” The GOP message had gotten through.

Shortly after Congress passed the law in March, with the polls showing deep public skepticism, David Axelrod told ABC News: “I think as the American people become familiar with what this program is and what it isn’t, they’re going to be very, very happy with it.”

Seniors with super high drug expenses were supposed to like the $250 rebate, but it is the proverbial drop in the bucket for those whose drug expenses mount in the thousands, and those who remember that the idea of allowing the government to negotiate with drug makers to bring prices down, too, was thrown under the bus. Even though young adults can now get coverage under their parents’ insurance, some are finding that’s not as easy as it sounds.

Others are learning that the law has consequences they weren’t told about. The president said many times people could keep the insurance they had if they liked it. Reform would not affect them. Lifting the lifetime cap, for example, affects only those with catastrophic expenses which most people don’t have. Instead, those whose medical expenses are low are now seeing their premiums rise to cover the additional risk the country’s for-profit insurers must now assume for lifting the cap and other new provisions the law calls for.

In late summer, at a road show cum pep rally in Philadelphia organized by Families USA, the group’s deputy director, Kathleen Stoll, told the crowd, mostly seniors, “there has been a lot of misinformation about Medicare and it’s very frustrating.” But the bait and switch continued. I don’t remember hearing the mandate mentioned, but Stoll did promise “we’ll see insurance more affordable.”

Politico’s Budoff Brown tells us that the Dems are running for cover, reporting that Senate Democrats up for reelection, like California’s Barbara Boxer and Colorado’s Michael Bennet, don’t even mention the law in the health sections of their campaign websites, and don’t take credit for its passage. Obama himself, she reported, does mention the law, “but it’s usually just a few lines wedged between the economy and the financial regulatory overhaul.” How’s that for leadership?

A few years ago, speaking at the annual meeting of the Association of Health Care Journalists, Don Barlett, of the esteemed reporting team of Barlett and Steele, told journalists that we are lying to our readers. I don’t know that we’ve lied as much as ignored parts of the story that mattered to people. My town halls show that there are large segments of the public that still don’t know about the law, and others don’t know what or who to believe.

Campaign Desk repeatedly noted that stories about how reform would affect ordinary people were MIA. “There’s a real danger reform will pass without families knowing what’s in store for them, financially speaking,” I wrote. How can we expect the results to be any different?

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.

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